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Nursing 171 > Week 9: NURS 171: Health Promotion and Part 2 Fluid, Electrolyte, Acid-Base Balance > Flashcards

Week 9: NURS 171: Health Promotion and Part 2 Fluid, Electrolyte, Acid-Base Balance Flashcards

1
Q

Health Promotion: Levels of Prevention

A
  • primary
  • secondary
  • tertiary
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2
Q

Health Promotion: Levels of Prevention: Primary

A 
Prevent/ slow onset of disease
(no illness)
-eating healthy foods
-exercising
-sunscreen
-seat belt
-immunizations
ex: begin with weight bearing exercises as ages
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3
Q

Health Promotion: Levels of Prevention: Secondary

A 
Detect and treat illnesses in early stages
-screening activities and education for detecting illness in early stages:
>breast self exam
>testicular exam
>physical examinations
>BP and diabetes screening
>TB test
ex: colonoscopy
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4
Q

Health Promotion: Levels of Prevention: Tertiary

A

Stopping disease progression; return to pre-illness state

  • stopping the disease from progressing
  • returning the individual to pre-illness phase
  • rehabilitation is main intervention
    ex: total hip replacement
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5
Q

Hypovolemia

A

deficient fluid volume; not enough fluid

-fluid volume (and electrolytes) deficient from ECF

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6
Q

Causes for Hypovolemia

A
  • surgery
  • trauma
  • dehydration
  • fluid loss (bleeding)
  • fluid shifts (ascites, into pleural space around lungs)
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7
Q

Signs + Symptoms of Hypovolemia

A 
-Dehydration
>thirst
>increased heart rate
>blood vessels constrict to maintain BP
>temperature rises due to inability to cool self through perspiration
>orthostatic hypotension
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8
Q

Alterations in Lab Values in Hypovolemia

A
  • Increased BUN
  • Increased Creatinine Ratio
  • Increased Urine Specific Gravity
  • Elevated Hematocrit
  • Less water related to solid substances (less water than solutes)
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9
Q

Risk for Hypovolemia

A
  • older adults (less muscle, water stored there, less stores)
  • infants
  • children
  • patients with fluid loss
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10
Q

Hypervolemia

A

excessive retention of sodium + water in ECF

too much fluid

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11
Q

Causes of Hypervolemia

A
  • over-hydration (IV, Oral)
  • excess salt intake (retain fluid)
  • kidney or liver disease
  • poor pumping action of the heart
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12
Q

Signs + Symptoms of Hypervolemia

A
  • Increased BP, bounding pulse
  • Pale, cool skin
  • Edema/ Ascites
  • Increased respirations + shallow
  • Crackles
  • Rapid weight gain
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13
Q

Alterations in Lab Values for Hypervolemia

A
  • Decreased BUN
  • Decreased Hematocrit
  • Decreased Urine Specific Gravity
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14
Q

Preventing Hypervolemia

A
  • monitor intake and output

- monitor intravenous and place on electronic pump

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15
Q

White Blood Cells (WBC)

A

(5- 10 x 10^3 mm^3)
primary cell fighting infection and tissue damage
-measured in lab study CBC

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16
Q

Platelets

A

(150,000- 400,000 mm^3)
help the clotting process by sticking to the lining of blood vessels
-measured in the lab study CBC

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17
Q

Laboratory Studies Used to Evaluate Fluid + Electrolyte + Acid-Base Balance

A
  • Complete Blood Count (CBC)
  • Serum Electrolytes
  • Serum Osmolality
  • Urine Osmolality
  • Urinalysis
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18
Q

Lab Study: Complete Blood Count (CBC)

A
  • fluid status is reflected

- measures RBC, Hgb (hemoglobin), HCT (hematocrit), WBC, Platelets

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19
Q

Hemoglobin

A

the iron-containing pigment of red blood cells that carries oxygen from the lungs to the tissues
-measured in the lab study CBC
(Males: 14- 18 g/dL)
(Females: 12-16 g/dL)

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20
Q

Hematocrit (HCT)

A

a measure of the % of the red blood cells in whole blood
-as fluid level decreases, % of cells in ratio to blood increases
-as fluid levels increase, % of cells falls
-measured in the lab study CBC
(Males: 42- 52%)
(Females: 37- 47%)

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21
Q

Lab Study: Serum Electrolytes

A

sodium, potassium, chloride and bicarbonate (electrolytes)

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22
Q

Lab Study: BUN, Creatinine

A

sensitive measures of fluid status + kidney function
(BUN: 10- 31mg/dL)
(Creatinine: Male 0.6- 1.2 mg/dL, Female: 0.5- 1.1 mg/dL)

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23
Q

Lab Studies: Glucose

A

a simple sugar that is the end product of carbohydrate metabolism
(70- 110 mg/dL)

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24
Q

Lab Study: Serum Osmolality

A

measures solute concentration of blood

  • increased means fluid volume deficit
  • decreased means fluid volume excess
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25
Q

Lab Studies: Urine Osmolality

A

measures solute concentration of urine

  • increased = fluid volume deficit
  • decreased = fluid volume excess
26
Q

Lab Study: Urinalysis

A

measures pH + specific gravity
-pH reflects acidosis + alkalosis
-specific gravity reflects fluid status
(increased specific gravity = fluid levels are low)
(decreased specific gravity = fluid is plentiful)

27
Q

Facilitating Fluid Intake

A
  • establish desired intake
  • develop fluid schedule
  • fluids may be given by mouth, via a tube, or intravenous
  • replacement via NG or feeding tube if GI Tract intact
  • parenteral intake may be needed
  • set goal for the day (ie. 2500 mL over 24 hours)
28
Q

Facilitating Fluid Restriction

A
  • for a variety of reasons (impaired cardiovascular, liver, or renal function)
  • determine amount of fluid allowed per shift
  • usually includes all forms of intake (PO and IV)
  • inform patients + caregivers of amount allotted
  • offer ice chips + frequent oral hygiene for comfort
  • keep liquids away from bedside
29
Q

Intravenous Solutions

A

-Isotonic
-Hypotonic
-Hypertonic
(classified according to how they compare to the osmolality of blood serum (275-290 mOsm/Kg))

30
Q

Isotonic Fluids

A

(250-375 mOsm/Kg)
-remain in the blood vessels
Ex:
0.9% NaCl= normal saline, lactated ringers

31
Q

Hypotonic Solution

A

(< 250 mOsm/Kg)
-pull water out of blood vessels into cells
Ex:
D5W and 0.45 NaCl = half normal saline

32
Q

Hypertonic Soluton

A 
pulls water into the blood vessels 
-volume expanders
(if i am putting more solutes, the water is going to come to the blood vessels)
Ex:
-D5 0.9% NaCl
-D5 0.45% Nacl
-D5RL
33
Q

8 Blood Types

A 
4 Groups: A, B, AB, O
-A (+ or -)
-B (+or -)
-AB (+ or -)
-O (+ or -)
>inherit from parents
>must receive only blood that is compatible with own blood group
-Rh factor determines if you are (+) or (-); present (+), not present (-)
34
Q

Cross-matching

A
  • once blood passed initial screen test
  • occurs between donated blood + potential donors blood
  • identifies minor antigens that will affect the compatibility of the donor blood in the recipient
  • RBC from donor are mixed with plasma from recipient
  • if testing shows the risk of transfusion is low = safe to transfuse
35
Q

People with Rh (+) may receive

A

Rh (+) or Rh (-) blood

36
Q

People with Rh (-) may only receive

A

Rh (-) blood

37
Q

Blood type O (-) is considered

A

a universal donor

38
Q

Blood Type AB (+) is considered

A

a universal recipient

39
Q

Blood Typing + Cross-matching Screen Tests

A

Hep B, Hep C, HIV, West Nile, Syphillis

40
Q

Blood Products

A
  • Whole Blood
  • Red Blood Cells (RBC)
  • Plasma
  • Platelets
  • White Blood Cells (WBC)
41
Q

Blood Products: Whole Blood

A

contains RBC, WBC and platelets suspended in plasma

42
Q

Blood Products: Red Blood Cells

A

-removed from whole blood for transfusion
-RBC that are transfused (packages RBCs or PRBCs) can raise clients hematocrit (HCT) + hemoglobin (Hgb) level while minimizing an increase i volume
(most common transfusion)

43
Q

Blood Products: Plasma

A
  • liquid portion of blood
  • makes up 55% of blood volume
  • includes albumin, clotting factors, immune globulins (may be transfused as a whole or be separated)
44
Q

Blood Products: Platelets

A

help the clotting process by sticking to the lining of blood vessels
(150,000- 400,000)

45
Q

Blood Products: White Blood Cells

A

for clients with infections not responsive to antibiotic therapy
(5- 10 x 10^3 mm^3)

46
Q

Initiating a Transfusion

A

-verify written prescription for the blood
-identify patient
-obtain vital signs prior to initiating
>if temp elevated, notify healthcare provider
-inspect intravenous site for patency + size
-identify blood product
-inspect IV site

47
Q

Transfusion Reaction

A
  • ensure to follow all safety checks + protocols
  • start transfusion slow
  • remain with patient for first 5 minutes
  • assess again at 15 minutes
48
Q

Examples of Transfusion Reactions

A
  • allergic
  • bacterial
  • febrile
  • hemolytic
  • circulatory overload
49
Q

Transfusion Reaction: Allergic

A 
allergy to blood being transfused
-Signs + Symptoms:
>flushing
>itching
>wheezing
>urticaria (hives)
>anaphylaxis
50
Q

Transfusion Reaction: Allergic Nursing Responsibilities

A
  • stop transfusion
  • replace with saline solution
  • notify physician immediately
  • administer prescribed antihistamine
51
Q

Transfusion Reaction: Bacterial

A 
contamination of blood
-Signs + Symptoms:
>fever
>chills
>vomiting
>diarrhea
>hypertension
52
Q

Transfusion Reaction: Bacterial Nursing Responsibilities

A
  • stop transfusion
  • replace with saline solution
  • notify physician immediately
  • administer prescribed antibiotics
  • treat symptoms
53
Q

Transfusion Reaction: Febrile

A 
temperature elevation due to sensitivity to WBCs, plasma protein or platelets
-Signs + Symptoms:
>fever
>chills
>warm, flushed skin
>aches
54
Q

Transfusion Reaction Febrile Nursing Responsibilities

A
  • stop transfusion
  • replace with saline solution
  • notify physician immediately
  • treat symptoms
55
Q

Transfusion Reactions: Hemolytic

A 
destruction of RBCs as a result of infusing incompatible blood
-Signs + Symptoms:
>fever
>chills
>dyspnea
>chest pain
>tachycardia
>hypotension
>can be fatal
56
Q

Transfusion Reactions Hemolytic Nursing Responsibilities

A
  • stop transfusion
  • replace with saline solution
  • notify physician immediately
  • send blood including tubing and filters along with sample of venous blood and first voided urine to lab for analysis
  • treat shock
57
Q

Transfusion Reaction: Circulatory Overload

A 
administering too great volume or too rapidly
-Signs + Symptoms:
>persistent cough
>crackles (lung sound)
>hypertension
>distended neck veins
58
Q

Transfusion Reaction Circulatory Overload Nursing Responsibilities

A
  • slow or stop transfusion
  • monitor vital signs
  • place client upright
  • notify physician
59
Q

Guidelines for Measuring Intake

A
  • identify factors that can affect fluid intake
  • measure intake: oral (liquids or those that melt at room temp), intravenous fluids, enteral or parenteral nutrition fluids
  • record info per policy
  • document in mL
60
Q

Guidelines for Measuring Output

A
  • urine output
  • empty wound drains or other devices + measure volume
  • record per policy
  • be aware of insensible losses that can not be measured (wound dressing, perspiration)

Nursing 171 (38 decks)

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